Postpartum Depression

Postpartum depression (PPD) is feelings of failure, guilt, loneliness and low self esteem lasting longer than two weeks or beginning two weeks or more after delivery. 50-80% of women experience the “baby blues,” a period characterized by feelings of restlessness, anxiousness, fatigue and loneliness which usually subside by the 10th postpartum day. This condition is mild and transient (Wong, 2006). 10-15% of women experience postpartum depression, typically with the classic symptoms of depression, sadness, crying, withdrawal and sleep disorders.


The woman may fear harming her baby or have thoughts of suicide. PPD is one of the most commonly undiagnosed conditions after childbirth. Approximately 40% of cases go unnoticed. Generally this is due to the mother’s embarrassment, guilt or fear of the feelings she is having and more often than not, she will not voluntarily admit to this kind of emotional distress (Wong, 2006). Recently the public has become aware of this ailment due largely to celebrities coming forward about their experiences with PPD. This publicity is helping women suffering from PPD to understand it and seek treatment. The nurse’s role in educating patients to prevent PPD, recognizing signs and symptoms of PPD and successful care of women suffering from PPD is essential to the health of the mother and her baby.
Nurses can educate new mothers and their families to help prevent postpartum depression in a number of ways. The precise cause has not been identified but is a combination of biochemical, psychological, social and cultural factors. Changes in hormone levels, fatigue due to childbirth, demands of the newborn, feelings of loss when separated from the newborn and cultural norms regarding the mother’s behavior are just some of the contributing causes of PPD. Informing clients of the predisposing characteristics and circumstances that place them at risk is the first key step. Issues such as prenatal depression, maternal history of depression, lack of social support, life stress, child care stress, maternal blues, marital dissatisfaction and prenatal anxiety should all be considered during conversation with the mother during both prenatal and postnatal visits. Another significant aspect is that at childbirth, the focus of attention transfers from the pregnant mother to the newborn. Continuing to support and care for the mother would help to reduce depression as well as help family members recognize symptoms of PPD. Flexible, mother-focused support from community providers may decrease the prevalence of PPD (Watt, 2002). Educating the mother and family on signs and symptoms is an important tool. These include feelings of distress, not being able to identify the source of the distress, and expressing undue concern about the health of their infant or themselves. Signs and symptoms of PPD are similar to any depressive state and consist of feelings of disappointment or apathy, sadness, insomnia, headache and anger for no justifiable reason.
Postpartum depression can interfere with maternal role attainment and may result in delayed maternal infant bonding. Because of this, nurses should seek education to better recognize early signs and symptoms of PPD and should include knowledge on assessing patients who are at risk. Risk factors for PPD are increased anxiety during pregnancy, ambivalence about pregnancy, previous postpartum depression, previous mental health disorders, previous problems with premenstrual syndrome, marital discord, poor extended family support, low socioeconomic level and a history of abuse, neglect or alcoholism. Screening tools such as the Edinburgh Postnatal Depression Scale and Beck’s Postpartum Depression Checklist may be used (Creehan, 2007). A nurse who identifies and addresses these issues early on is able to assist the new mother with seeking treatment, supporting her and being empathetic to her feelings (Castine, 2007).
Nurses play a crucial role in providing interventions and treatment for postpartum depression, beginning with identification. Screening for risk factors is the first crucial step to discovering PPD. Next, assessing the mother’s mood and affect as well as the interactions between the mother and infant is critical. The mother is very vulnerable during this immediate postpartum period so the nurse must focus on showing support and caring. Informing the mother of strategies for feeling rested are napping when the baby does and letting someone else take care of the household chores. Discuss planning self care with the mother, such as taking a walk, reading a book, having a date with her significant other and spending time with friends. Encouraging the mother to share her feelings will also improve her well being. Encouraging breast feeding is an important role the nurse can play at this time. It can help the mother bond with her newborn and results in the mother feeling pleased. Crying is also beneficial to the postpartum woman. Psychologically, it is expressive, and physiologically, it rids the body of toxins and hormones (Fooladi, 2006). This can alleviate some of the depressive feelings the new mother has. The nurse can also promote support within the family by discussing the condition and ways they are able to help the new mother. The nurse can also help the mother get in touch with support groups and programs in the community that would be beneficial to her. When depressive symptoms continue beyond the “baby blues” period, it is important to assist women in seeking medical treatment. Medical management of PPD includes pharmacological intervention. Antidepressants such as Tegretol or Depakote are necessary in most cases. Psychotherapy is another important step in the treatment process and is focused on her fears and concerns regarding her new responsibilities and roles as well as monitoring for suicidal or homicidal thoughts (Wong). Possible alternative or complimentary therapies include acupuncture, acupressure, aromatherapy, herbs, healing or therapeutic touch, massage, relaxation techniques, reflexology and yoga.
Postpartum depression is a condition that is treatable, however it is commonly undiagnosed. Nurses are able to offer much support, guidance and knowledge to these mothers. Their role is essential in the education, recognition and successful care of women suffering from PPD.

A. Intervention 1: Focus on diagnosing postpartum depression
a. Disadvantage 1: It is difficult to assess for postpartum depression due to several factors.
The length of stay in the hospital after a vaginal delivery is forty eight hours and for a cesarean section it is ninety six hours. (Datar & Sood, 2006) This amount of time allows primary care providers to ensure the physical health of the mother and newborn as well as keeping the cost of childbirth reasonable. This amount of time does not, however, allow sufficient time to monitor mental health conditions. The first postpartum check-up takes place six weeks after birth during which the provider will perform a physical examination and discuss any concerns the new mother is having. Many women suffering from postpartum depression feel embarrassed and choose not to share their feelings. After the six-week check-up, the focus turns to the infant, without further follow up for the mother (Gjerdingen & Center, 2003). With so few opportunities to assess for PPD, it’s difficult to diagnose every case.
b. Disadvantage 2: Embarrassment may hold women back from sharing feelings.
Women are expecting a period of adjustment during the postpartum period and may not realize that what they are experiencing is abnormal. (Epperson, 1999) The period directly after giving birth is very new to first time mothers. There is a feeling of pressure to be a “good mother”. If and when depressive feelings come about, she doesn’t know how to handle it during a time that is supposed to be the happiest in her life. Because of this, it is less likely that she will seek professional assistance. Denial of the classic depressive symptoms of postpartum depression delays treatment and ultimately delays normal mother-child bonding as well. Due to the very few opportunities the primary care provider has to diagnose PPD, it is important that women be educated about PPD. This will likely help them understand their feelings and seek treatment.

B. Intervention 2: Continuing to support and care for the mother postpartum
a. Disadvantage 1: Taking the time to do self care
The demands of motherhood can be overwhelming, especially if there is also strain on the mother’s relationship with her significant other or their finances. Everything is new, and taking care of your own child is exciting and frightening at the same time. These women often have responsibilities they feel that they must do on their own including cooking, cleaning and caring for the infant while trying to recover from giving birth. In order to relieve everyday stresses incurred by the new mother, she must learn to perform self-care (Cheng, 2006). The new mother needs to take time for herself. Things such as resting and exercising will help with her physical health. But self-care is so much more than that. She must let her family and friends help her with household chores and remember that she doesn’t have to do everything by herself. The new mother also needs to take care of her emotional needs by having a date with her partner and spending time with friends. Getting out of the house to go for a walk can do wonders for stress. Talking about feelings with a significant other, family and friends will help the new mother identify any depressive symptoms she may be having as well as improve her emotional health overall (Cheng, 2006).
b. Disadvantage 2: Finding the time, energy, courage and resources to get involved in support groups.
New mothers are overwhelmed with their new duties and lifestyle. There are some strategies for coping with the stress that goes along with this such as asking for help, setting daily goals, and discovering new activities. There are support groups available for just about any condition and postpartum depression is no different. It is usually difficult for women to discuss their feelings, especially if they are embarrassed of those feelings. Talking about them with a group of strangers can be quite intimidating. There are many resources available on the internet, such as Postpartum Support International (http://www.postpartum.net/index.html) . Providing information about support groups during well child check-ups may help new mothers realize that support is out there and will hopefully seek it out if she is not comfortable discussing her feelings with her provider yet (Cheng, 2006).

Resources

Castine, J. & Walton, J. (2007, March 14-20). Postpartum depression negatively impacts child development. Michigan Chronicle, p. B8.

Cheng, C., Fowles, E., & Walker, L. (2006). Postpartum maternal health care in the United States: A critical review. Journal or Perinatal Education, 15(3). Retrieved February 4, 2008 from PubMedCentral database.

Creehan, P. & Simpson, K. (2007). Perinatal Nursing (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. pp. 492-512.

Epperson, C. (1999). Postpartum major depression: Detection and treatment. American Family Physician, 59(8). Retrieved February 4, 2008 from American Academy of Family Physicians News and Publications database.

Fooladi, M. (2006). Therapeutic tears and postpartum blues. Holistic Nursing Practice, 20(4), 204-. Retrieved January 3, 2007 from Expanded Academic ASAP database.

Gjerdingen, D., & Center, B. (2003). First-time prenatal to postpartum changes in health, and the relation of postpartum health to work and partner characteristics. Journal of the American Board of Family Medicine, 16. Retrieved February 4, 2008 from Journal of the American Board of Family Medicine database.

Hendrick, V. (2003). Treatment of postnatal depression: Effective interventions are available, but the condition remains underdiagnosed. British Medical Journal, 327(7422). Retrieved January 3, 2007 from PubMedCentral database.

Lieu, T., Braveman, P., Escobar, G., Fischer, A., Jensvold, N. & Capra, A. (2000). A randomized comparison of home and clinic follow-up visits after early postpartum hospital discharge. Pediatrics. 1058. Retrieved January 3, 2007 from Expanded Academic ASAP database.

Watt, S., Sword, W., Krueger, P., & Sheehan, D. (2002). A cross-sectional study of early identification of postpartum depression: Implications for primary care providers from The Ontario Mother & Infant Survey. Journal of BioMed Central Family Practice, 3. Retrieved February 20, 2007 from PubMedCentral database.

Wong, D., Perry, S., Hockenberry, M., Lowdermilk, D.L. & Wilson, D. (2006). Maternal child nursing care (3rd ed.). St.Louis: Mosby, Inc. pp. 619-621, 638-9, 674-9.

The Role of the Nurse in Postpartum Depression. (n.d.). Retrieved February 5, 2007, from http://www.awhonn.org/awhonn/?pg=873-6230-7000-4730-4770